Provider Demographics
NPI:1740290865
Name:FOOTHILL PODIATRY CLINIC OF GRASS VALLEY INC
Entity type:Organization
Organization Name:FOOTHILL PODIATRY CLINIC OF GRASS VALLEY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:CONNIE
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-477-7200
Mailing Address - Street 1:152 CATHERINE LN STE F
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5756
Mailing Address - Country:US
Mailing Address - Phone:530-477-7200
Mailing Address - Fax:530-477-1246
Practice Address - Street 1:152 CATHERINE LN STE F
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5756
Practice Address - Country:US
Practice Address - Phone:530-477-7200
Practice Address - Fax:530-477-1246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1740290865Medicaid
CAZZZ06288ZOtherBS
CA1740290865Medicaid
CA4846060002Medicare NSC